Non-invasive Mapping-Guided Atrial Fibrillation Ablation

The aim of this study is to test the feasibility and potential of a personalized, non-invasive mapping-guided ablation approach in patients with persistent atrial fibrillation (AF), who are unlikely to benefit from empirical pulmonary vein isolation alone. As a pilot study, it is designed to assess feasibility and procedural efficacy and potential signals of harm.

General Strategy:

Patients with persistent AF planned for catheter ablation are eligible in case of left atrial enlargement.

The study intervention consists of

• Empirical pulmonary vein isolation in all patients (current standard of care).
• A personalized ablation approach targeting up to three additional atrial regions which harbour critical AF-perpetuating sources:

• Target regions are selected based on the spatiotemporal Stability of Atrial High-Rate Activity (SAHRA) using a non-invasive global mapping system (Acorys, Corify Care).
• Selected target regions displaying stable high-rate activity are isolated or homogenized according to predefined regional borders based on the 15-segment bi-atrial model of the EHRA and EACVI Clinical Consensus on Standardized Atrial Regionalization (Althoff et al. 2025).

Inclusion criteria

Ablation-naïve patients with:

• Persistent AF planned for catheter ablation plus
• Left atrial enlargement (LA diameter ≥45 mm or LA volume index ≥35ml/m2 or LA area ≥20 cm2)

Exclusion criteria

• Previous cardiac ablation
• Age <18 years
• Pregnancy or lactation
• Previous stroke/TIA
• Severe left ventricular dysfunction (LVEF <35%)
• Renal failure (GFR <30 ml/min)
• Dermal disease or hypersensitivity predisposing for skin irritation or exanthema